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Current Clinical Issues |

Strategies to Stop Abuse of Prescribed Opioid Drugs

Jennifer Fisher Wilson
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Potential Financial Conflicts of Interest: None disclosed.

Ann Intern Med. 2007;146(12):897-900. doi:10.7326/0003-4819-146-12-200706190-00017
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Prescription opioids have substantially and safely improved the quality of life for many patients disabled by pain, but they are also commonly misused and abused. Opioid analgesics are the second most commonly abused drugs in the country, falling after marijuana and before cocaine, according to the National Survey on Drug Use and Health by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). The addictive nature of opioids is nothing new; however, there has been an alarming increase in the number of people misusing and becoming addicted to these prescription analgesics.

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Abuse of Prescribed Opioids: the role of Addiction Medicine Specialists and Buprenorphine
Posted on June 21, 2007
Lawrence S Greenfield MD
No Affiliation
Conflict of Interest: None Declared

Letter to the Editor:

The Current Clinical Issues: Stategies to Stop Abuse of Prescribed Opioid Drugs by Ms Jennifer Fisher Wilson, Science Reporter, (Ann Int Med 2007;146:897-900) fails to mention Addiction Medicine specialists and underrates the potential for methadone diversion.

Though "pain management specialists" are suggested in the article as the consultants for pain "patients with a high risk for abuse" or those with "a history of addiction," readers should be informed that another group of specialists, identified by their membership in and certification by the American Society of Addiction Medicine (ASAM), are available for consultation regarding these patients.

Specialists in Addiction Medicine come from a variety of medical specialties and subspecialties. ASAM was admitted to the American Medical Association (AMA) House of Delegates as a voting member in 1988, and in 1990 the AMA added Addiction Medicine (ADM) to its list of designated specialties. Further information about ASAM and its members can be found at the www.asam.org.

The article also suggests "managing pain primarily with long-acting opioids that have a low street value, such as methadone" as one of the "methods for preventing misuse" of opioids. The "street value" of methadone should not be underestimated; the DEA identifies methadone as one of the "commonly abused pharmaceuticals" at www.dea.gov.

A potentially safer alternative opioid for pain management of patients with risk factors for addiction or a history of addiction is buprenorphine, an opioid with mixed characteristics (partial mu agonist and kappa antagonist). Buprenorphine, available in two sublingual forms as Subutex and Suboxone (the former contains solely buprenorphine and as such has potential for diversion and IV misuse while the latter contains buprenorphine with naloxone making its potential for IV misuse negligible), is available by prescription by physicians who hold a special waiver issued by the DEA to prescribe the drug for persons suffering with the disease of addiction (1), though the drug can be prescribed by any physician "off label" solely for pain management for patients without addiction (2,3). Caution must be exercised in switching any patient from a full opioid agonist to a partial opioid agonist, given the risk of precipitating opioid withdrawal (4).

Lawrence S Greenfield, MD Apollo Beach, FL lsgmd4@yahoo.com

1. US Department of Health and Human Services. Substance Abuse and Mental Health Administration. Center for Substance Abuse Treatment. Buprenorphine: Physician Waiver Qualifications. Available at: http://buprenorphine.samhsa.gov/waiver_qualifications.html.

2. Sublingual Buprenorphine is Effective in the Treatment of Chronic Pain Syndrome. Malinoff, Herbert et al. Am J Therapeutics, 2005;12:379- 384.

3. Helping 'Them:' Our Role in Recovery from Opioid Dependence. Loxterkamp, David. Ann Fam Med, 2006;4:168-171.

4. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Alford, Daniel P. Ann Intern Med, 2006;144:127-34.

Conflict of Interest:

None declared

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